Income Protection Solutions

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1 Income Protection Solutions Adviser s Data Capture Form Please note that this is NOT an Application Form The purpose of this form is to help you, the Adviser, gather information from your client before submitting it on their behalf using our online application method. Any Adviser Data Capture Forms received by Aviva will be returned to sender. In order to provide a decision on your client s application as soon as possible, and minimise the need for additional evidence we will contact your client to discuss their medical and lifestyle over the phone. If your client would be unable to provide this information over the phone, for example if they are a non-english speaker or they are deaf or hard of hearing, please print a PDF application for them to complete. IMPORTANT NOTE: In the unlikely event that non-disclosure is found it may be necessary to cancel the plan or reconsider the terms offered to your client.

2 Adviser Details Aviva Agency code FSA Registration Number Quote Details Cover and benefit required Increasing by, if applicable after weeks deferred Which Income Protection Solution option would you like, please tick one: Guaranteed Rates and index linking option Guaranteed Rates no index linking option Reviewable Rates and index linking option Limited Benefit Term Age at which you require cover to cease (available options: any age from 50 to 70 inclusive) Details of person to be Policyholder Surname Mr / Mrs / Miss / Ms Sex M / F Forenames Date of birth Marital status Address Postcode Address What would be the best way to contact you? Telephone Letter Text What is your nationality? e.g. British Do you permanently reside in the UK? If yes, how many years have you lived in the UK? 2

3 In order to complete your application Aviva will arrange for you to be contacted by telephone for an interview. To ensure the best chance of contacting you please provide as many numbers as possible, the best time for us to call, any time you may be unavailable, and also details of any planned holidays. Contact Telephone Numbers: Daytime Mobile Evening Specific times when it may be more convenient to call Please state any dates or times when you are unlikely to be available Are you employed, self-employed or a house person? Employed: What are your normal gross annual earnings? Earnings Year Self-employed: What are your normal gross annual earnings (after the deduction of income tax as expenses) as assessed for tax purposes (your share of net profit)? Please provide figures for the last 3 years. Earnings Year Earnings Year Earnings Year When we assess your claim you have the option to select at outset which basis you would prefer, either the last 12 months or the average of the last 36 months net profits. Which would you prefer? Last 12 months Average of last 36 months Please complete this section if Self-employed As you have stated that you are self employed we need to ask a few more questions. How long have you been self employed? If you have been self-employed for less than twelve months please can you tell us your previous occupation? Please state the duties of your previous occupation What industry did you work in? Please state your previous annual taxable earnings from your previous occupation 3

4 Other Insurances Continued Income In the event of incapacity, would you receive income from your employer? Please ensure the deferred period(s) selected expires after income ceases What percentage of salary do you receive? % for weeks Do you receive any further support? If yes, please provide details (including percentage of salary and number of weeks): Other Insurances Existing Benefits Existing Income Protection Benefit Are you currently insured or applying for any other Income Protection contracts which will remain in force on acceptance of this plan? If yes, please advise: Increasing by, if applicable after weeks deferred Increasing by, if applicable after weeks deferred Insurer Termination age Do you have any further Income Protection contracts? If yes, please provide details: 4

5 Existing Mortgage Payment Protection (MPPI) Benefits Are you currently insured or applying for any other MPPI contracts which will remain in force on acceptance of this plan? If yes, please advise: Insurer Payment Term weeks Do you have any further MPPI products? If yes, please provide details: Existing Loan Protection Benefits Are you currently insured or applying for any other Loan Protection contracts which will remain in force on acceptance of this plan? If yes, please advise: Insurer Payment Term months Do you have any further Loan Protection products? If yes, please provide details: Existing Waiver of Premium Insurance Are you currently insured or applying for any other Waiver of Premium contracts which will remain in force on acceptance of this plan? If yes, please advise: Insurer Payment Term years Do you have any further Waiver of Premium products? If yes, please provide details: 5

6 Your Occupation What is your occupational title? What industry do you work in? What percentage of your occupation is manual? (We class manual as heavy physical work or using industrial machinery or tools) What percentage of your occupation is clerical/administrative? Does your occupation involve any of the following: Working at heights of over 30 feet? If yes, please state the amount of time spent working at over 30 feet, and also the maximum height at which you work: Working underground or underwater? If yes, please state the amount of time you spend working underwater or underground, and specify whether you work underwater or underground, or both: Working with hazardous materials or solvents? If yes, please specify the percentage of time you spend with hazardous materials work or solvents in your main occupation, and also provide details of the hazardous materials: Working offshore? If yes, please specify the percentage of time spent offshore in your main occupation: How many hours do you work in your main occupation per week? Hours How long have you been in your current occupation? Years Months Do you have a second occupation? If yes, please provide details (including details requested in the previous questions about your main occupation): Have the earnings from this occupation been taken into account when calculating the level of cover required? 6

7 Business Travel / Vehicles Used What is your annual business mileage? Miles per annum If you drive any vehicle for your job, please tell us the type make and model of the vehicle you drive. If you use a Fork Lift Truck, please state the percentage of your work time spent driving this. % Does your occupation involve working, travelling or residing outside the United Kingdom, or do you have intention to do so? General Practitioner s details (complete in block capitals) It may be necessary for us to contact your doctor after you have been interviewed, for further medical information. However this will only happen once we have reviewed any information you provided in your medical interview. Please give the name, full address and telephone number of your usual doctor Postcode Tel. If you have been registered with this doctor for less than six months, please also give the name and address of your previous doctor Postcode Tel. Your Authorisation To avoid delay do you wish to set up an Electronic Direct Debit Instruction (DDI)? Do you wish to pay monthly or annually? Monthly Annually Please provide your preferred day of the month for payment to be taken and cover to commence (1st to 28th only) D D M M Y Y Y Y Are you the account holder? Are you able to authorise direct debits from this account? Your bank details If you have answered yes to both of the above questions, please complete the following section: Please provide your bank / building society s name Please provide their address Postcode Please provide the account holder s name Please provide the sort code - - Please provide your account number (please note for Girobank customers provide the last 8 digits only) 7

8 Aviva Health UK Limited. Registered in England Number Registered Office 8 Surrey Street rwich NR1 3NG. This insurance is underwritten by Aviva Insurance Limited. Registered in Scotland Number 2116, Registered Office Pitheavlis, Perth PH2 0NH. Authorised and regulated by the Financial Services Authority. Aviva Health UK Limited, Head Office: Chilworth House Hampshire Corporate Park Templars Way Eastleigh Hampshire SO53 3RY. GEN /2011 Aviva plc

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